Endoclips

All patients were given the “French” position before surgery, where the primary surgeon stood between the patient’s legs, first assistance stood at the primary surgeon’s right side and second assistance stood at his left side. Five ports were used: First a 10-mm trocar was placed 2 cm to the left of the midline above the umbilicus for optical view, then a 15-mm trocar was placed into the right midclaviculer-line, then a second 10-mm trocar was placed into the left midclavicular-line, afterwards a 5-mm trocar was placed into the sub-xiphoid area as liver retractor and at last a second 5-mm trocar was placed into the left subcostal area to pull the stomach.
The stomach was completely mobilized from the greater omentum side, beginning at the line of incisura angularis by LigaSure™ (Covidien, USA). At first proximal dissection was performed up to the angle of His, distal dissection was performed until to the pylorus. Then a 36 F bougie was inserted by the anesthesiology team along the lesser curvature of the stomach. Antral resection was started 2–4 cm from the pylorus and continued up to 0.5–1 cm medial to the angle of His. Hemostasis was checked and provided by Endoclips™ (Covidien, USA). Possible leakage was checked with methylene blue in saline given through the bougie.

On the theater table, the patient was placed in the supine split-leg position “French position”. First, a supraumbilical optical port (10 mm) was placed 2 cm to the left. The other ports were placed in the following manner: a 15 mm port at 4 cm to the right of the supraumbilical port, a 5 mm port 4 cm to the left of the supraumbilical port, a 5 mm port in the subxiphoid zone (for liver retraction), and a 5 mm trocar in the left mid-axillary line (to raise the stomach). Starting from the pylorus, a LigaSure™ (Covidien, USA) was used to completely release the greater curvature of the stomach from the greater momentum. The dissection was carried out up to the angle of His. Then, the anesthesiologist inserted a 36-F bougie along the lesser gastric curvature. Antral resection was started 2–6 cm from the pylorus and proceeded up to the angle of His 0.5–1 cm from the pylorus using endo GIA ultra-universal stapler with reloads (by Covidien, USA). In Group 1, resection of the antrum began 2 cm from the pylorus, and in Group 2, resection began 6 cm from the pylorus. Endoclips™ (Covidien, USA) or 3/0 Vicryl sutures were used to provide hemostasis. Methylene blue solution (in saline) was applied via the bougie to test for leakage.